Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 759 MD (2005/06)
Maryland Important Notice
Regarding Replacement
Use ACORD Maryland Important Notice Regarding Replacement (ACORD 759 MD), to
inform the Carrier of the intent to replace a policy. The form is to be completed by the
Producer and then sent to the new Carrier.
IDENTIFICATION SECTION Company
Name and Address of Insurance
Name of Insurance Company must be inserted before this form is used. Use the actual
name of the company. Do not use group names.
REPLACEMENT OF LIFE
INSURANCE OR ANNUITIES existing policy or contract?
1. Are you considering
discontinuing making premium
payments, surrendering, forfeiting,
assigning to the insurer, or
otherwise terminating your
Answer by checking the appropriate box.
REPLACEMENT OF LIFE
INSURANCE OR ANNUITIES on the new policy or contract?
2. Are you considering using
funds from your existing policies
or contracts to pay premiums due
Answer by checking the appropriate box.
REPLACEMENT OF LIFE
INSURANCE OR ANNUITIES Insurer Name
Indicate the name of the insurer of the existing policy or contract that is being considered
for replacement.
REPLACEMENT OF LIFE
INSURANCE OR ANNUITIES Contract or Policy #
Indicate the contract or policy number of the existing policy or contract that is being
considered for replacement.
REPLACEMENT OF LIFE
INSURANCE OR ANNUITIES Insured or Annuitant
Indicate the name of the insured or annuitant of the existing policy or contract that is being
considered for replacement.
REPLACEMENT OF LIFE
INSURANCE OR ANNUITIES Replaced /Financed
Indicate whether each policy or contract will be replaced or used as a source of financing.
REPLACEMENT OF LIFE
INSURANCE OR ANNUITIES Being Replaced Because:
The Existing Policy or Contract is
Indicate the reason you are contemplating replacing your current policy or contract.
REPLACEMENT OF LIFE
INSURANCE OR ANNUITIES contract.
1. I hereby acknowledge that only
insurer-approved sales material
was used in the sale of the new
Answer by checking the appropriate box, whether or not only insurer-approved sales
material was used in the sale of the new contract.
ACORD 759 MD (2005/06)
1 of 2
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 759 MD (2005/06)
Maryland Important Notice
Regarding Replacement
Use ACORD Maryland Important Notice Regarding Replacement (ACORD 759 MD), to
inform the Carrier of the intent to replace a policy. The form is to be completed by the
Producer and then sent to the new Carrier.
REPLACEMENT OF LIFE
INSURANCE OR ANNUITIES applicant.
2. I hereby acknowledge that all
sales material used in the sale of
the new contract was left with the
Answer by checking the appropriate box, whether or not all sales material used in the sale
of the new contract was left with the applicant.
PRODUCER'S
CERTIFICATION
Producer's Signature
Producer must sign the form.
PRODUCER'S
CERTIFICATION
Date
Date the producer signed the form.
APPLICANT'S
CERTIFICATION
Applicant's Initials
Applicant must initial the form if they do not want the notice read aloud to them.
APPLICANT'S
CERTIFICATION
Applicant's Signature
Applicant must sign the form.
APPLICANT'S
CERTIFICATION
Date
Date the applicant signed the form.
ACORD 759 MD (2005/06)
2 of 2